Looking at New Ways to Address Unique Challenges: Environmental Considerations for Long Term Care

Author: Amanda Thornton, CIC, RN, MSN

The setting of a long-term care (LTC) environment is incredibly complex and poses unique challenges for cleaning and disinfection.  LTC is not only a healthcare setting but also the place that residents call their home. This can pose distinct questions as to how cleaning and disinfection should best be done to prevent the spread of disease to the vulnerable population within. The residents that live in LTC are particularly susceptible to infections due to age-related comorbidities as well as a decline in overall immune defenses.

To compound the difficulty, many of the physical structures are older and contain carpeted hallways and other soft surfaces that are easily contaminated. What can the Infection Preventionist do to help mitigate the infection risks within LTC? Let’s look at a few important points to remember when approaching the environment of care.

Establishing Cleaning and Disinfection Practices

Perhaps the first thing to establish when thinking about a long-term care setting is cleaning and disinfection practices that are thorough, effective, and efficient. Many studies show that environmental services staff (EVS) wipe down only 50% or less of surfaces¹. Visual inspections and rounds are not enough by themselves to ensure quality oversight.

The CDC states that for surfaces to be cleaned appropriately there should be a consistent pattern for the cleaning of rooms and shared equipment, as well as clearly established assignments of who is to clean what². Also, following the same pattern, every time makes it easier to ensure consistent cleaning. Quality monitoring can be improved with the use of a checklist or other audit tools. Including the EVS staff in quality oversight and the use of these tools allows them to feel a sense of shared responsibility and gives them feedback which increases engagement and motivation.

The Importance of Cleaning Schedules

With increasing efforts to provide person-centric facilities such as the “Eden Alternative” approach³, it has never been more important to consider the relevance of cleaning schedules that revolve around the residents’ needs and are appropriate for the ongoing activities. For example, mopping the activities room when bingo is being played or cleaning the dining room during mealtime is not a person-centered approach.

Cleaning of residents’ rooms can be particularly challenging, especially if the resident is resistant to the efforts of the EVS staff due to dementia, paranoia, or other issues such as hoarding.  Striking a balance between the resident’s rights and the importance of environmental cleanliness is key and should be a part of the resident’s care plan through a multidisciplinary team.

How often to clean and what to clean can sometimes be confusing in LTC.  The Association for Professionals in Infection Control and Epidemiology (APIC) recommends the following ⁴:

1. Establish a schedule for ALL surfaces to be cleaned routinely using an EPA-approved hospital-grade disinfectant.
2. Clean spills and hard surfaces as needed in-between the routine cleaning.
3. Vacuum all carpets daily.
4. Clean high-touch surfaces daily and more often during outbreak situations.
5. Use a horizontal wet dusting technique vs dry dusting.
6. Use all disinfectants according to their instructions for use, including the recommended contact times.

While cleaning and disinfection can often be a tedious task, studies show that the environment and survival of pathogens on surfaces contribute to healthcare-associated infections (HAI’s)⁵. Some pathogens can survive on surfaces for weeks or even months, still posing a threat of infection. A decline in the available number of trained EVS staff during the pandemic has made it even more challenging for LTC facilities to protect their residents.

New Technologies Improving Surface Disinfection

Fortunately, there are technologies on the market for surface disinfection that are rising to the top as winners for HAI prevention. UV technology has been successfully used in the LTC setting ⁶ and has been shown to reduce pathogens on surfaces by 94% when used during terminal cleaning ⁷.

Surfaces, especially in high-touch areas, are consistently contaminated so disinfection on a frequent basis is critical, though rarely achieved. Another new surface technology is a product that can achieve continuously active disinfection for ESKAPE pathogens (CAD) for up to twenty-four hours despite touching and re-inoculations of the surface. The technology lies in the patented polymer within the disinfectant which, when applied to the surface, actually “binds” to the surface and is not wiped off or removed.

The disinfectant provides continuous antimicrobial activity despite lots of touches or recontamination. In addition to CAD, this product serves as an intermediate level disinfectant, a soft surface sanitizer, and 7-day mildew and fungal preventative, compatible with many healthcare surfaces making, it truly a versatile product for many situations. Can you imagine how useful this will be in settings such as long-term care?

When used as an enhanced environmental disinfection strategy, the most frequently touched surfaces will be protected by an antimicrobial shield interrupting the chain of contamination. Ideal areas of use for this disinfectant within LTC include:

• Waiting Areas
• Nurses Stations
• Elevators
• Light switches
• Railings
• Doorknobs
• Shared equipment
• Salon areas
• Rehab areas

There has never been a better time to consider such technologies than this time of increased awareness around infection control practices, including environmental cleaning and disinfection.  With increased focus and resources available for these efforts, LTC facilities should consider the implementation of newer technologies for daily disinfection needs and the protection of their residents.